<!DOCTYPE html>
<html lang="zh" xmlns:th="http://www.thymeleaf.org" >
<head>
    <th:block th:include="include :: header('修改押金补缴')" />
</head>
<body class="white-bg">
    <div class="wrapper wrapper-content animated fadeInRight ibox-content">
        <form class="form-horizontal m" id="form-payment-edit" th:object="${depositPayment}">
            <input name="id" th:field="*{id}" type="hidden">
            <div class="form-group">    
                <label class="col-sm-3 control-label">用户名：</label>
                <div class="col-sm-8">
                    <input name="synUserName" th:field="*{synUserName}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">效验码：</label>
                <div class="col-sm-8">
                    <input name="synKey" th:field="*{synKey}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">住院号：</label>
                <div class="col-sm-8">
                    <input name="inHosNo" th:field="*{inHosNo}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付类型：</label>
                <div class="col-sm-8">
                    <select name="payType" class="form-control m-b" th:with="type=${@dict.getType('his_pay_type')}">
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}" th:field="*{payType}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付交易流水号：</label>
                <div class="col-sm-8">
                    <input name="payRecord" th:field="*{payRecord}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">预交金金额：</label>
                <div class="col-sm-8">
                    <input name="payMoney" th:field="*{payMoney}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付交易返回：</label>
                <div class="col-sm-8">
                    <input name="payReturn" th:field="*{payReturn}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付状态：</label>
                <div class="col-sm-8">
                    <select name="successfulPayment" class="form-control m-b" th:with="type=${@dict.getType('his_payment_state')}">
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}" th:field="*{successfulPayment}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">终端号：</label>
                <div class="col-sm-8">
                    <input name="terminalCode" th:field="*{terminalCode}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">商户订单号：</label>
                <div class="col-sm-8">
                    <input name="outTradeNo" th:field="*{outTradeNo}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">微信订单号：</label>
                <div class="col-sm-8">
                    <input name="transactionId" th:field="*{transactionId}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">商户id：</label>
                <div class="col-sm-8">
                    <input name="appId" th:field="*{appId}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">床号：</label>
                <div class="col-sm-8">
                    <input name="bedNo" th:field="*{bedNo}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">患都姓名：</label>
                <div class="col-sm-8">
                    <input name="patientName" th:field="*{patientName}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">科室名称：</label>
                <div class="col-sm-8">
                    <input name="departmentName" th:field="*{departmentName}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">押金余额：</label>
                <div class="col-sm-8">
                    <input name="depositMoney" th:field="*{depositMoney}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">医保类型名称：</label>
                <div class="col-sm-8">
                    <input name="medicalTypeName" th:field="*{medicalTypeName}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">his接口返回信息：</label>
                <div class="col-sm-8">
                    <input name="resultMsg" th:field="*{resultMsg}" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">his接口返回信息：</label>
                <div class="col-sm-8">
                    <input name="resultCode" th:field="*{resultCode}" class="form-control" type="text">
                </div>
            </div>
        </form>
    </div>
    <th:block th:include="include :: footer" />
    <script th:inline="javascript">
        var prefix = ctx + "his/payment";
        $("#form-payment-edit").validate({
            focusCleanup: true
        });

        function submitHandler() {
            if ($.validate.form()) {
                $.operate.save(prefix + "/edit", $('#form-payment-edit').serialize());
            }
        }
    </script>
</body>
</html>